NSTEMI: What to Do When Initial Antiplatelet Therapy, Anticoagulation, and Supportive Care Have Not Controlled Ischemic Chest Pain or Achieved Target Oxygenation
Clinical scenario
This protocol applies to patients with non-ST-elevation myocardial infarction (NSTEMI) who have received a first-line medical regimen — including antiplatelet therapy, anticoagulation, and supportive measures targeting pain control and oxygenation — and for whom the primary symptom goals have not been met.
Reason for escalation
The preceding treatment line — aspirin plus a P2Y12 inhibitor, anticoagulation, and symptom-directed supportive care (supplemental oxygen and analgesics) — was directed at two primary goals: maintaining oxygen saturation at or above 90%, and achieving relief of ischemic chest pain. Failure to meet either target is the indication for this next-line protocol.
Next-line approach (partial overview only)
This protocol specifies an invasive coronary strategy — angiography with intent to revascularize — to be carried out during the current hospitalisation; the complete approach, procedural details, and access-site recommendations are available in the full protocol.
References
DOI: 10.1161/CIR.0000000000001309
- In patients with NSTE-ACS who are at intermediate or high risk of ischemic events and are appropriate candidates for revascularization, an invasive approach with the intent to proceed with revascularization is recommended during hospitalization to reduce MACE.
- In patients with ACS undergoing PCI, a radial approach is preferred to a femoral approach to reduce bleeding, vascular complications, and death.
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